Can tinnitus cause non‑cardiac chest pain?

Tinnitus Does Not Cause Non-Cardiac Chest Pain

Tinnitus is an auditory symptom—the perception of sound without an external source—and has no established mechanism to produce chest pain. The two conditions may coexist in the same patient, but there is no causal relationship between them.

Why This Question Arises: Overlapping Psychological Comorbidities

Shared Psychiatric Factors

• Anxiety and depression are common comorbidities in both chronic tinnitus and non-cardiac chest pain, which may explain why patients sometimes present with both symptoms simultaneously. 1, 2
• Approximately 11% of non-cardiac chest pain in general practice and 8% in emergency departments is attributed to psychiatric causes such as anxiety disorders, panic attacks, and somatoform disorders. 1, 3
• Chronic disabling tinnitus impairs psychological and psychiatric well-being, often resulting in high healthcare utilization, but this psychological distress does not directly cause chest pain. 2

Cognitive-Behavioral Therapy Benefits Both Conditions

• Cognitive-behavioral therapy reduces chest pain frequency by 32% in patients with non-cardiac chest pain and is the most valuable evidence-based intervention for bothersome tinnitus, suggesting that shared central nervous system mechanisms related to symptom perception—not direct causation—may link the two. 1, 2

Pathophysiology: No Anatomic or Physiologic Connection

Tinnitus Mechanisms

• Tinnitus results from functional changes in the auditory nervous system caused by neural plasticity, with symptoms referred to the ear even when peripheral auditory pathology is no longer active. 4
• The condition shares similarities with central neuropathic pain and paresthesia, but these are neurological phenomena affecting sensory perception, not mechanisms that generate chest pain. 4

Non-Cardiac Chest Pain Mechanisms

• Non-cardiac chest pain arises from gastrointestinal (GERD is the most common esophageal cause), musculoskeletal (costochondritis accounts for 43% after cardiac exclusion), pulmonary, or psychological sources—none of which are influenced by auditory system dysfunction. 1, 5
• Central nervous system-visceral interactions, low pain thresholds, hyperbody vigilance, and sympathetic activation are proposed mechanisms for non-cardiac chest pain in patients with psychological disorders, but these do not involve the auditory pathways affected in tinnitus. 1

Critical Pitfall: Assuming Coexistence Implies Causation

• When a patient with tinnitus presents with chest pain, the chest pain must be evaluated independently using standard diagnostic algorithms for acute coronary syndrome, aortic dissection, pulmonary embolism, and other life-threatening causes. 1
• Obtain a 12-lead ECG within 10 minutes and measure high-sensitivity cardiac troponin immediately in any patient with acute chest pain, regardless of concurrent tinnitus. 1
• Do not attribute chest pain to tinnitus or dismiss cardiac evaluation simply because the patient has a known auditory symptom. 1

Algorithmic Approach When Both Symptoms Are Present

Step 1: Immediate Cardiac Exclusion

• Perform ECG within 10 minutes and draw high-sensitivity troponin to rule out acute coronary syndrome. 1
• Assess for life-threatening causes: aortic dissection (sudden "ripping" pain, pulse differential), pulmonary embolism (tachycardia >90% of cases, pleuritic pain), tension pneumothorax (unilateral absent breath sounds). 1, 5

Step 2: Evaluate Non-Cardiac Chest Pain Etiologies

• If cardiac causes are excluded, systematically assess:
  • Gastrointestinal: GERD (burning retrosternal pain, meal-related, antacid relief), esophageal spasm (may respond to nitroglycerin, so nitroglycerin response should not be used diagnostically). 1, 5
  • Musculoskeletal: Costochondritis (pain reproducible with palpation of costochondral junctions, worsens with chest wall movement). 1, 5
  • Psychological: Anxiety, panic disorder, somatoform disorder (associated with dyspnea, palpitations, diaphoresis). 1

Step 3: Address Psychological Comorbidities

• For patients with recurrent chest pain, negative cardiac workup, and coexisting tinnitus, referral to a cognitive-behavioral therapist is reasonable because both conditions share psychological perpetuating factors. 1, 2
• Treat active psychiatric conditions (anxiety, depression) with appropriate pharmacotherapy and psychotherapy, as these may amplify symptom perception in both tinnitus and non-cardiac chest pain. 1, 2

Step 4: Manage Tinnitus Independently

• There are no proven effective pharmacological treatments for chronic disabling tinnitus; management focuses on cognitive-behavioral therapy, hearing aids when coassociated hearing loss is confirmed, and treatment of psychiatric comorbidities. 2
• Tinnitus management does not influence chest pain, and chest pain management does not influence tinnitus. 4, 2

Common Clinical Scenarios

Scenario 1: Patient with Known Tinnitus Presents with New Chest Pain

• Evaluate chest pain using standard protocols—tinnitus is irrelevant to the differential diagnosis. 1
• Do not delay cardiac workup or attribute symptoms to the patient's auditory condition. 1

Scenario 2: Patient with Non-Cardiac Chest Pain Also Reports Tinnitus

• Both symptoms may reflect shared anxiety or somatization, but each requires independent evaluation and management. 1, 2
• Consider cognitive-behavioral therapy as a unifying intervention for patients with both conditions and underlying psychological distress. 1, 2

Scenario 3: Patient Attributes Chest Pain to Tinnitus-Related Stress

• Acknowledge the patient's perception but clarify that tinnitus does not directly cause chest pain; stress and anxiety may exacerbate both symptoms. 1, 2
• Perform full cardiac evaluation before attributing chest pain to psychological factors. 1